Coordinated health and human services delivery system and process

ABSTRACT

A system ( 200 ) and method ( 500 ) is provided for a coordinated health care service delivery program. The method can include providing services to clients at high risk for chronic disease including co-morbidities and consequent disabilities associated with the chronic disease, linking community and vocational services ( 130 ) for facilitating community inclusion to supplement fundamental clinical and economic goals, creating a comprehensive and dynamic individual development plan ( 222 ) to involve the client and family members as active program team members for stressing client-centric collaborative goal setting, and applying action learning ( 226 ) to promote behavior modification and lifestyle change.

CROSS REFERENCE TO RELATED APPLICATION

This application claims benefit of U.S. Provisional Application No.60/654,932, filed Feb. 23, 2005, entitled “Coordinated Health and HumanServices Management Network”, by Jay E. Yourist, Karl J. Krieger, RobertL. Dilworth, and Zuhair Latif, which is hereby incorporated byreference.

FIELD OF THE INVENTION

The embodiments of the invention herein relate to management systems,and more particularly a method of health and human services delivery.

DESCRIPTION OF THE RELATED ART

The management practices of the healthcare system evolved in response tothe high incidences of acute illnesses. However, over the last fiftyyears the prevalence of chronic illness has risen significantly. Chronicdisease is a leading cause of disability and consequently unemploymentfor special needs populations including the elderly and disabled.Indirect non-clinical care costs frequently associated with disability,dependency, and joblessness are higher than the direct clinical carecosts. Chronic disease is a leading cause of disability and unemploymentundermining worker productivity and employability. Persons with chronicconditions may be less likely to work and may be more likely to havelower incomes. Minority populations have also demonstrated a higherincidence of chronic conditions, primarily diabetes and ensuingdisability, further disenfranchising those particular populations.

Historically, healthcare practices were not coordinated but episodic andfragmented thereby proving to be increasingly inefficient for treatingindividuals of chronic diseases. In addition, service providers did notreadily have access to client information which resulted in limitedservice delivery and cost inefficiency. Healthcare expenditures havesteadily increased due to unnecessary hospital admissions, expensive andindecisive technologies, and the accumulation of conflicting clinicaldata. These expenditures have not provided substantive improvements inhealth status, community integration, or independent living.

Over the last twenty five years, policies and programs have been enactedto integrate services in order to promote cost efficiency and improvethe quality of health care for such plans. Notably, the US Congress,through the Rehabilitation Act of 1973 and the IDEA Act of 1988,developed a policy to deliver a comprehensive plan to providecoordinated services to both adults and children with disabilities.Attempts to integrate or coordinate all or a part of the necessaryservices to achieve coordinated health care services have formerlyincluded Disease and Care Management Programs, Workers CompensationsPrograms, Vocational Rehabilitation (Rehabilitation Act of 1973), IDEAAct of 1988, Ticket to Work Program, Comprehensive Elder Programs(PACE), Social HMOs, California Medi-Cal model for persons withdisabilities (CHAT), Community Health Information Network (CHIN), andIntegrated Healthcare Management (IHM).

The Ticket to Work Program; the Medicaid Buy-In; Benefits Planning,Assistance and Outreach (BPAO); and Protection and Advocacy forBeneficiaries of Social Security (PABSS) were all key initiativescontained in the Ticket to Work and Work Incentives Improvement Act of1999 (TWWIIA) for increasing employment outcomes for beneficiaries. Thegoal of the Ticket Program was to give disability beneficiaries theopportunity to achieve long-term employment by providing them greaterchoices and Confidential (Social Security Administration) SSA ContractProposal opportunities for employment. The legislation also removedbarriers that previously influenced individual's choices betweenhealthcare coverage and work. However, despite significant efforts bythe SSA to provide employment opportunities such as the “Ticket to WorkProgram”, less than 1% of all disability program beneficiaries return togainful employment. (Wehman, 2003 a)

Considerable evidence and testimony from beneficiaries, advocates andproviders have noted significant weaknesses in the Ticket to WorkProgram namely; 1) eligibility criteria exclude certain beneficiarieswith significant return to work potential, 2) conflicts exist betweenthe vocational rehabilitation system and the Ticket Program, and 3) theprovider payment system has failed to recruit sufficient providers toguarantee beneficiary choice in job training and supports. Fewbeneficiaries and even fewer providers are participating in the Ticketprogram. The national statistics for Ticket assignments as of Sep. 27,2005 indicate that 11,038,798 Tickets were issued and 104,537 tickets(0.95%) were assigned which is less than 1% of the total ticketdistribution. Of those assigned Tickets 96,358 were assigned toVocational Rehabilitation agencies (92.2%) and 8,179 to EmployerNetworks (ENs) (7.8%). These statistics mirror with those ticketassignment statistics in the State of Florida.

For example, in the State of Florida as of Sep. 27, 2005 out of 678,489eligible ticket holders, only 5,688 Tickets were assigned (0.84%). Ofthe assigned tickets, 578 tickets were assigned to ENs (10%) and 5,110Tickets were assigned to Florida's Division of Vocational Rehabilitation(90%). These numbers parallel national statistics where, nearly ninetypercent of the current participants of the Ticket Program have beenassigned to VR agencies. Consequently, overwhelming use of State VRagencies and the low numbers of ENs assisting current “Ticket” holdersindicate that the goals of the Ticket Program to enhance access toservices, primarily employment, are not being met. Studies have shownthat beneficiaries would prefer to be employed if their primary benefitscould remain intact, especially healthcare.

The Social Security Administration supports two disability programs:Social Security Disability Insurance (SSDI) and Supplemental SecurityIncome (SSI). The programs consume approximately five percent of thefederal budget, and are projected to become much more costly through2012. The Ticket to Work and Work Incentives Improvement Act of 1999 wasenacted to provide employment opportunities for beneficiaries,potentially reversing the growing claimant burden on the Social SecurityAdministration. This has met with limited success and the suggestedreforms and barrier removal strategies to improve the delivery of theTicket Program tend to focus on policy changes and administrativesystems in isolation, rather than following a holistic, integrative or atotal systems approach. As the “baby boomer” population reaches the agewhere they are more susceptible to disability, critical economic issuesimpacting employment and rising health insurance costs can be expectedto accelerate growth of these Social Security disability programs.

It has been verified that educating participants to make positivelifestyle choices can significantly reduce the complications attributedto chronic disease and disability. However, the traditional health careprograms have been fragmented and ineffective. The policies and programswere mainly aimed at integrating primary and specialty healthcareservices. They were not successful due in large part to the practicalinability to access and share medical data. A major barrier to providingsuch services was also conflicting business interests, namely thereluctance for multiple healthcare providers to cooperate and coordinatetheir services due to increased competition. In addition, individualhealth and economic prosperity have typically been managed independentlyand in isolation with regard to the overall management of healthcare,wellness, community and vocational service delivery. The dissociationhas compounded the problem to the detriment of both healthcare andeconomic remedies.

A need therefore exists for integrating and coordinating healthcarewellness, disease prevention, social, and employment service functionsinto a health care program to improve the quality of life for specialneeds populations such as elderly populations, minority populations,uninsured and underinsured populations, and persons with disabilitiesincluding those having chronic illness. Such a program can prepare aparticipant for employment, independence, and improved quality of life.In particular, a need also exists to establish a system to promotegainful employment for SSDI/SSI beneficiaries by providing amulti-disciplinary support system of services that promotes long termbehavior modification, self-determination and systems change.

OBJECT OF THE INVENTION

An object of the invention is to bring together an array of interlockingmodalities and constructs in ways that are mutually reinforcing and apart of one single overarching system. Typically, individual health caresystem components, such as peer support teams and circles, are usuallyused in isolation from one another rather than in juxtaposition withother systems or components of systems. In other cases there is no knownexisting parallel to these system pieces; that is, the manner in whichprinciples of action learning are to be employed. The system componentinvolved within the context of the invention, even if similar to systemsthat are already available in some form in the market place, have beenspecifically tailored to fit within the overall coordinated human andhealth services and delivery system to promote synergy. A core essenceof the embodiments of the invention, as well as the uniqueness, is inits broad integration of essential services as a single system. Thesystem is designed to holistically provide the necessary supportmechanisms and services to not only improve the health status of thosewith chronic disease and disabilities of clients, but also to improvetheir quality of life, build their self-efficacy and level ofself-confidence, and position clients for reentry into the workforce.

Referring to FIG. 1, an illustration for a connectivity of services isshown. The illustration represents the services as pieces of a puzzleconnected together by an information technology (IT) platform. The ITplatform is just one embodiment demonstrating how various system piecescan be widely integrated from a process standpoint, in support ofchronic disease management, social services and support for those withchronic disease and/or disabilities. Various embodiments of theinvention, in addition to the IT embodiment, are herein contemplated.The IT component can be considered as a tool to facilitate servicecoordination and data collection and analysis for a continuum ofavailable services. Understandably, information technology can beinterwoven throughout the services and delivery system in ways thatoptimize the sharing of critical information, both within the specificsystem and with external organizations, such as VocationalRehabilitation. As a result, a coordinated human and health services anddelivery program can be established wherein case management under such aprogram can become much more efficient. Rather than a series ofindividual and isolated system components or services, the frameworkcreates an open system for coordination of services from the standpointof information sharing across agency and organizational lines.

The business methods underlying the system of coordinated health andhuman service delivery herein presented can be applied to variouscontexts and operations. For example, the system can be configured totarget Social Security Disability Insurance (SSDI) or Social SecurityInsurance (SSI) beneficiaries. Understandably, these beneficiaries areunique and require a broad range of support services to sustaincommunity integrations which the coordinated health and human servicedelivery of the invention is uniquely adapted to provide. Thecoordinated health and human service delivery herein presented isflexible and adaptable to such unique demands. In one particularexample, Federal and State systems have been minimally successful inenticing such individuals to actively return to the workplace (i.e., TheTicket-To-Work program). Consequently, one aspect of the invention isconfigurable for addressing the complexity of this problem. Theembodiment of the invention can prove highly effective in providingcoordinated services to other clientele groups as well. For instance, inone aspect, the underlying business methods can be readily customized toserve the elderly or to operate in different cultures in the Unitedstates or elsewhere. The system can evolve and adapt over time due tothe inherent system flexibility afforded by the uniqueness and noveltyof the coordinated delivery services model.

In certain aspects, the business methods underlying the system ofcoordinated health and human service delivery can be consideredmulti-disciplinary; that is, a holistic support system, whichfacilitates the linkage and efficient management of integratingclinical, community and vocational services. Accordingly, the system asa whole creates a seamless continuum of one coordinated serviceinfrastructure. Notably, the execution of healthcare and social servicesin existence today is highly fragmented and not coordinated. Theindependent service modules are themselves not unique, but thearchitecture and deployment of this invention provides a coordinatedsystem of essential services that represents a unique and novel systemsapproach.

The purposeful departure from independent service delivery is a hallmarkfeature of this invention. The underlying business methods of theinvention provide an innovative approach that represents a paradigmshift in traditional case management and service delivery for primarycare, specifically aimed at chronic disease and disability management.In one aspect, the invention is an evidence-based, population-basedmodel that delivers culturally-relevant services customized for anypopulation demographic, but is especially applicable for minority,underserved and underinsured communities with particular chronicdiseases and/or disabilities. Uniquely designed, it employs actionlearning principles and peer support teams which foster individualresponsibility and self-management under the auspices of supportservices mechanism and network, with the oversight of an advisory bodyof stakeholders. In one embodiment, the effective integration of theseotherwise disparate services is realized through a proprietary ITplatform.

In one aspect, for purposes of practical illustration, the method ofcoordinated services provided by the invention can promote gainfulemployment for SSDI/SSI beneficiaries through the deployment of aprimary care and social delivery system in an underdeveloped country. Itshould be understood that the underlying business methods supporting thecoordinated network of human and health services delivery may be appliedto a variety of populations, particularly underserved communities, inneed of coordination and/or consolidation of services.

Thus, in one aspect, the invention can provide a coordinated servicessupport network to promote coordinated human and health servicesdelivery for participant beneficiaries by providing a multi-disciplinarysupport system of services that promotes long term behaviormodification, self-determination and systems change. This can include,but is not limited to,

A. Developing a logistics infrastructure and training staff to provideessential services.

B. Partnering with Disability Vocational Resource (DVR) providers as acollaborator in most aspects of program from participant recruitment,plan development to data capture, analysis and evaluation.

C. Partnering with local and state agencies, to provide: 1) changemanagement training; 2) appropriate program “cross training”, and 3)information capture, sharing and analysis.

D. Recruiting and establishing a stakeholder provider network;Confidential SSA Contract Proposal.

E. Instituting a proactive recruitment strategy to enroll qualifiedSSDI/SSI beneficiary candidates.

F. Customizing self-management content targeting the broad needs ofprogram participants in the areas of vocational, job readiness training,and health and fitness;

G. Articulating document and track Individual Development Plans (IDP) tocapture personal and program goals for each participant, focusing onempowerment, self determination and employment goals.

H. Providing a secure IT platform to facilitate timely communicationbetween program stakeholders and a virtual service coordination tool.

I. Designing and building a HIPPA compliant database to capture,archive, disseminate and analyze health, job readiness, economic andquality of life data.

SUMMARY

A health care delivery system and program is provided that coordinateshuman and health services to enhance gainful employment throughindividual development and principles of Action Learning. Thecoordinated human and health delivery system fosters self determinationthrough “peer support” teams and multidisciplinary private/publicpartnerships which promote the capacity, quality and improvedsustainability of healthcare, community service and meaningfulemployment opportunities.

In one aspect, embodiments of the invention concern a business methodfor coordinated health care services and delivery. The method caninclude providing services to clients at high risk for chronic diseaseincluding co-morbidities and consequent disabilities associated with thechronic disease, linking community and vocational services forfacilitating community inclusion to supplement fundamental clinical andeconomic goals, creating a comprehensive and dynamic individualdevelopment plan to involve the client and family members as activeprogram team members for stressing client-centric collaborative goalsetting, and applying action learning to promote behavior modificationand lifestyle change. Notably, the creation of the integrateddevelopment plan and the coordination of services is a fundamentalfeature to the inventive method of doing business.

The method can further include focusing on reach-out goals of theclient's improved quality of life by encompassing clinical, social, andvocational measures and outcomes. This can include integrating acomprehensive set of healthcare, vocational, community integration andeducation services, coordinating and maintaining connectivity of theservices while providing overall communication among programstakeholders, and providing tools and suitable media for customized datacollection, capture, analysis, archiving, communication and informationsharing. Notably, the development of an Individual Development Plan(IDP) in combination with self management education can promote personalaccountability. Accordingly, utilization of action learning and peersupport team principles can promote a client's self determination,advocacy, gainful employment and independence. The action learning canempower clients to solve problems with peers and case managers, whereinthe problems may be associated with a clients' health management serviceand reimbursement policies.

In one aspect, the method can further include measuring and analyzingoutcomes, and validating premises based on outcome indicators andmetrics. Monitoring the implementation and coordination of the serviceswith the care plan can provide continuous quality improvement. In oneaspect, the data analysis results of the services can be combined withthe individual development plan for developing new cost/economic models.In addition, evaluative mechanisms can be imposed for streamliningaccountability of the coordinated health care services and deliveryprogram. The evaluative mechanisms can include efficacy of recruitment,attainment of IDP goals, clinical goals outcome, job readiness andactual placements, assessment of participant satisfaction, and qualityof life measures.

The method can further include providing a coordinated managementarchitecture that places peer support teams at the core of a servicedelivery model. The model can rely upon personal relationships, trustfactors, and emotional support established by peer-to-peer counseling.The peer support system can empower the client through customized selfmanagement education and problem solving skills for improving theclient's health, community integration, employment readiness, financialwell being, and overall quality of life.

In one arrangement, the coordinated health care delivery and servicescan be developed and implemented in phases consisting of primary andsecondary intervention strategies. For example, a Primary interventionscan be based on an individual development plan that focuses on anindividual beneficiary. The secondary intervention can be system-basedincluding clinical, educational, community, vocational services andbenefit counseling.

Embodiments of the invention also concern a comprehensive servicedelivery program for coordinated health and human services management.In one aspect, the service delivery program can facilitate healthcare,community and vocational services for both Social Security DisabilityInsurance (SSDI) and Supplemental Security Income (SSI) beneficiaries,primarily those with disabilities related to chronic disease. Theintegrated approach can be critical for facilitating and sustaininggainful employment. It can provide a comprehensive set of essentialcoordinated supports, including healthcare. In practice, the deliverymodel can provide a confidential program of comprehensive and culturallysensitive coordinated services and lifestyle reform initiatives toachieve successful outcomes, specifically overall improved quality oflife for persons with chronic disease and disabilities. The proposedprogram can target disability beneficiaries with, or at-risk for,chronic disease and disabilities.

The delivery program can provide services and products to manageparticipant problems in a useful, timely, efficient, cost-effective andparticipant-centric manner. Hospital staff members, healthcare providersand representatives of the pharmaceutical and medical device/researchand development industry, and the participant among many otherstakeholders, can be included within the delivery model to playimportant decision-making roles in determining and implementing the careplan for the participant's chronic illness. In one implementation, theprogram can target Ticket to Work assignees to VocationalRehabilitation. The implementation can provide gainful employmentopportunities and independent living, improved client-providerinteractions through accessible and coordinated support services,lifestyle changes/behavior modification through self-managementeducation and peer supported interactive problem solving, clientempowerment and self-determination, and improved quality of lifeoutcomes.

The delivery program can include an Individual Development Plan (IDP)that beneficiaries develop in conjunction with family members and otherprogram stakeholders. The IDP can be a dynamic, personal template thatarticulates the beneficiary's goals, and which can be facilitated by“Peer Support Teams” to promote behavioral and lifestyle change usingprinciples of Action Learning and interactive dialogue. The model canrepresent a paradigm change in traditional case management that can be aconsumer-driven approach to provide support service coordinationpromoting self-determination and self-advocacy. Through this SystemsApproach, Action Learning—based peer support, together with broadinformation sharing and analysis via an IT platform can facilitate thegoals of Ticket to Work legislation.

The delivery program can include an intake assessment and recruitmentmodule for population stratification and recruitment of clients havingchronic disease or disability, a primary intervention module fordeveloping an individual development plan and for enactingaction-learning through peer support team intervention, a secondaryintervention module for providing coordination of services through an ITplatform, an information archive to coordinate services for monitoringand tracking client progress, a delivery process module for placing aclient in a supportive, nurturing and learning environment for gainingaccess to the aforementioned services, and an evaluation module toanalyze and measure the effectiveness of the coordinated servicedelivery system with regard to the level of community integration andre-employment of the client.

Embodiments of the invention also concern a program for coordinatedhealth and human services delivery through an IT platform. The programcan include assessing and recruiting clients, developing a team ofprofessionals and third party providers, developing an individualdevelopment plan for the clients, supporting service groups and managingservices for clients through action-learning and peer support teamintervention, sharing and archiving information using an IT platform toconsolidate data from the services and for monitoring and trackingclient progress, delivering the services through the IT platform forproviding on-line access to a multi-disciplinary team of experts, andanalyzing and measuring the effectiveness of the coordinated servicedelivery program to provide healthcare, community integration, andemployment service performance to the client.

Embodiments of the invention concern an information technology (IT)platform for providing coordinated health care and human servicesmanagement. The platform can include a healthcare management service, aself-management service, a community and vocational service, and anoutcomes research service. The IT platform can be a population-based,client-centric entity that combines access to self-management programswith a comprehensive continuum of services to facilitate a clients'functional and psychosocial needs for focusing the client on communityintegration and re-employment.

BRIEF DESCRIPTION OF THE DRAWINGS

The features of the system, which are believed to be novel, are setforth with particularity in the appended claims. The embodiments herein,can be understood by reference to the following description, taken inconjunction with the accompanying drawings, in the several figures ofwhich like reference numerals identify like elements, and in which:

FIG. 1 depicts an information technology (IT) platform in accordancewith an embodiment of the inventive arrangements;

FIG. 2 illustrates a coordinated service delivery network in accordancewith an embodiment of the inventive arrangements;

FIG. 3 illustrates a coordinated service delivery network in accordancewith an embodiment of the inventive arrangements;

FIG. 4 illustrates a support service network in accordance with anembodiment of the inventive arrangements;

FIG. 5 presents a program for coordinated health and human servicesdelivery in accordance with an embodiment of the inventive arrangements;

FIG. 6 presents a flowchart for intake assessment and recruitment inaccordance with an embodiment of the inventive arrangements;

FIG. 7 presents a method for intake assessment and recruitment inaccordance with an embodiment of the inventive arrangements;

FIG. 8 illustrates an organization chart in accordance with anembodiment of the inventive arrangements;

FIG. 9 illustrates a peer support team coordination flowchart inaccordance with an embodiment of the inventive arrangements;

FIG. 10 illustrates a web-based portal in accordance with an embodimentof the inventive arrangements;

FIG. 11 illustrates an outcome report in accordance with an embodimentof the inventive arrangements; and

FIG. 12 depicts a client flow chart in accordance with an embodiment ofthe inventive arrangements.

GLOSSARY OF TERMS

A. Action Learning—Action Learning can be a process of reflecting onone's work and beliefs in an interactive and supportive environment ofone's peers for the purpose of gaining new insights and resolving realbusiness, personal or community problems in real time (expression ofself determination).

B. Advisory Council—A Project Advisory Council can consist of volunteerindividuals within the project's targeted population and criticalcommunity stakeholders will be created during the planning year andmaintained throughout the duration of the project. Its purpose can betwo-fold: 1) Assure the principles of Self-Determination are driving theactivities within the Peer Support Circles (PSCs) and Peer Support Teams(PSTs); and 2) Provide input into the Policy Implications component.

C. Coordinated Support Service Management—A multi-disciplinary approachto client-centered service that can seek to facilitate a continuum ofclinical, community and vocational services in a cost-effective mannerthat enhances service and ensures cost efficiency. It represents aparadigm change to traditional case management.

D. Employment Network (EN)—Federal term for provider agencies that canbe registered with a provider (such as Maximus) to deliver specificemployment supports and services to individuals activating their Ticket.

E. Future Search—Methodology for bringing together a representativegroup of approximately sixty-four to seventy-two principal stakeholders(e.g. community leaders) to discuss past, present and future, and arriveat “common ground” that may agree to in a specific of focus. In thiscase “common ground” can focus on employment for SSI/SSDI beneficiaries.

F. Individual Development Plan (IDP)—A dynamic comprehensive plandeveloped by the participant, Learning Coach, family members (atclient's election) and a Support Service Group Coordinator who candelineate the participant's overall individual clinical, community andemployment goals and the services required to meet those goals.

G. Individual Plan for Employment (IPE)—An IPE, can be developed by theindividual and the DVR Counselor, can be a description of the specificrehabilitation services that are needed for the individual to achieve anemployment outcome. The IPE can be designed to achieve the specificemployment outcome that is selected by the individual and consistentwith the individual's unique strengths, resources, priorities concerns,abilities, capabilities, interests and informed choice; and the IPE canresult in employment in an integrated setting.

H. Learning Coach (LC)—A person who can facilitate the activities of aPeer Support Team (PST), Peer Support Circle (PSC) or other ActionLearning Team that may be established. The Learning Coach can create anurturing environment that fosters the ability of the team to draw fromits collective strength in helping each individual team member improvetheir ability to master health related problems and better manage theirlives, in positioning themselves for job opportunities. Theresponsibility of the Learning Coach can extend to at least three peersupport teams (PST). Confidential SSA Contract

I. Peer Support Teams (PSTs)—The basic functional process and problemsolving group in which program services can be coordinated andself-management education and peer support counseling can be provided.Approximately twelve to eighteen participants can comprise each team andthe PST process can be facilitated by a “Learning Coach”.

J. Peer Support Circles (PSC)—A Peer Support Circle can be a subdivisionof a Peer Support Team (PST). It can have approximately four to sixmembers. There can be at least three PSCs in a PST, each functioning asa bona fide Action Learning team, with each team member empowered toself-determine the best personal strategies for improving their lifesituation. There may be no designated team leader. They can beself-directed teams. Team members can operate as equals, learn from andwith each other, reflect on what is being learned from their collectiveand individual actions, and can provide support to one another.

K. Quality of Life (QOL)—can refer to the sum of all things in anindividual's environment or personal make up that influence their life.The indicators can range from good health, to financial means,purposefulness of their existence, support of family and friends,ability to seek and gain meaningful employment, and feeling someconfidence in their future. QOL can be holistic and can recognize that agood quality of life may require a number of things to be in place todrive this end.

L. Self Determination—Self-Determination can be a philosophy of dailyliving focusing on a holistic, consumer-directed approach which can havefour overarching principles: (Nerney, T. and Shumway, D., 1996): •Freedom: Choosing where and with whom to live, how to make a living, andwith whom to develop relationships. • Authority: Being in control of howone's long-term care dollars are spent. • Support: Arranging publicresources in a way that meet the individual needs of a person. •Responsibility: Using public resources cost-effectively. • Confirmation:Recognizing that all individuals must play a major role in thedevelopment and implementation of self-determination policies.

M. Self-Management Education—The ability of participants to applyknowledge and practice skills to optimize their health and economicpotential, and quality of life in partnership with their peer supportand provider teams.

N. Support Service Group (SSG)—A service group within the CoordinatedSupport Service Model can be comprised of one Support Service GroupCoordinator who oversees at least three Learning Coaches in which eachcoach may be charged with at least three peer support teams. Therefore,each SSG can be composed of one Support Service Group Coordinator(SSGC), three Learning Coaches, one clerical and nine peer support teamscontaining approximately one hundred thirty five (135) participants intotal. This can be the basic service unit in which the primaryintervention of Support Service Coordination is provided through ActionLearning and services centered on each participant's IDP.

O. Support Service Group Coordinator (SSGC)—A person that can beassigned with the oversight of all services provided in a single SupportService Group which can usually be case management in nature. At leastthree learning coaches can be accountable to each Support Service GroupCoordinator.

P. Support Service Region (SSR)—Each region can represent onedemonstration site and there can be two Support Service Regions. Eachregion can contain two Support Service Groups.

Q. Support Service Network (SSN)—The Support Service Network can be thegroup of provider stakeholders that make up the basic four constituentservice domains: 1) clinical services; 2) educational services; 3)community services; and 4) vocational services.

R. Teams (two teams can be defined as follows:)—1) Task Teams—teams thatcan have an administrative focus in ensuring that processes arefollowed, making certain that educational components can be developedand in place, monitoring program progress and recommending any programadjustments, reviewing information flow and tracking evaluative results,and supporting the referral plan for services. 2) Action LearningTeams—In contrast to Task Teams, Action Learning Teams can be managed bythe participants themselves, with all team members as equals; theseteams (respective participants) can be empowered through self-managementeducation and problem solving skills to participate in the choice ofservices to improve their health, community integration, enhance theiremployment readiness and job placement.

DETAILED DESCRIPTION

While the specification concludes with claims defining the features ofthe embodiments of the invention that are regarded as novel, it isbelieved that the method, system, and other embodiments will be betterunderstood from a consideration of the following description inconjunction with the drawing figures, in which like reference numeralsare carried forward.

As required, detailed embodiments of the present method and system aredisclosed herein. However, it is to be understood that the disclosedembodiments are merely exemplary, which can be embodied in variousforms. Therefore, specific structural and functional details disclosedherein are not to be interpreted as limiting, but merely as a basis forthe claims and as a representative basis for teaching one skilled in theart to variously employ the embodiments of the present invention invirtually any appropriately detailed structure. Further, the terms andphrases used herein are not intended to be limiting but rather toprovide an understandable description of the embodiments herein.

The terms “a” or “an,” as used herein, are defined as one or more thanone. The term “plurality,” as used herein, is defined as two or morethan two. The term “another,” as used herein, is defined as at least asecond or more. The terms “including” and/or “having,” as used herein,are defined as comprising (i.e., open language). The term “coupled,” asused herein, is defined as connected, although not necessarily directly,and not necessarily mechanically. The term “program” as used herein, isdefined as system of services, opportunities, or projects, generallydesigned to meet a social need. In some embodiments, a computer readablemedium can be implemented in software for performing the method steps.The software may be embodied in an article of manufacture that includesa program storage medium such as a computer disk or diskette, a CD, DVD,RAM, flash memory, or other computer memory device. The machine-readablestorage can be encoded with a data structure that defines structural andfunctional interrelationships between the data structure and thecomputer software and hardware components which permit the datastructure's functionality to be realized.

Embodiments of the invention herein present a coordinated health andhuman services management program that provides a collaborativeenvironment between clinical providers, community service providers,clinical and social service researchers, clients and their families. Inone aspect, the management program can be deployed using an informationtechnology (IT) platform but is not restricted to such an embodiment.The web-base IT platform is presented merely to describe one possibleimplementation of the business methods of coordinated health and humanservices. The management program can be the application and deploymentof a set of business methods that when combined together provide acoordinated and holistic health care service. In practice, the programcan educate clients, also herein referred to as participants, to managedisability and chronic disease which includes the related disablingconditions associated with the chronic illness. In one aspect, theprogram can focus the client on their functional and psychosocial needsfor re-entering the work force and the community. The program can be apopulation-based, client-centric strategy that combines self-managementskills with a comprehensive continuum of services to facilitate acommunity integration and re-employment of the client. The services caninclude clinical, educational, community, and vocational services. Theprogram can integrate the service offerings to provide a holistic andnurturing atmosphere to treat an entire health condition such as chronicillness. The program can include intervention programs to elevateself-esteem and a sense of participant self-worth. The services can becustomized to the client's individual needs and dealt with in a caringenvironment where learning is encouraged. In one particular example, butnot herein limited, the program may target disenfranchised or minoritycommunities and the veterans population with, or at-risk for, chronicdisease and disabilities.

Referring to FIG. 1, a coordinated health care and human servicesmanagement program puzzle 100 is shown. The puzzle 100 can beinterconnected through a set of business methods that integrate varioushealth and human services programs. For example, the puzzle 100 caninclude a healthcare management service program 110, a self-managementservice program 120, a community and vocational service program 130, anoutcomes research service program 140, and an IT platform 150 serving asa coordination unit between the services 110-140. The pieces of thepuzzle are shown merely to illustrate the connection of services througha set of underlying business methods. The services 110-140 are depictedas pieces of a “care management puzzle.” In one arrangement, theindividual pieces can be connected and enabled by the IT platform 150,which can combine access to the services for coordinating and managingthe services within the puzzle 100. The puzzle 100 is not limited to theconnections and interconnections shown, and can include combinationsthereof in various arrangements. The puzzle 100 can link these serviceswith other services, consolidate data from the services 110-140, collectand analyze healthcare outcomes, and develop and refine clinicalprotocols from client health care data. In one aspect, data from theservices 110-140 can be normalized and analyzed to develop outcomehealth care studies for evidence-based healthcare programs. In practice,the business methods underlying the puzzle 100 can provide apopulation-based, client-centric approach that facilitates a focusing ofa client's functional and psychosocial needs on community integrationand re-employment through the coordination and interaction of theservices 110-140.

The underlying business methods of the invention provide a broad arrayof integrated services which can be implemented by means of theinformation technology platform 150. For example, one business methodcan capture clinical and cost data from “real-time” clinical andcommunity-based social and vocational services, includingprotocol-driven clinical trials. The method of doing business canprovide the continuity, consistency and efficiency to integrate andsynchronize the disparate delivery services 110-140 into a singlecoordinated information stream. The methods of doing business canimprove the participant/provider relationship by providing a healthcareclient with access to up-to-date information pertinent to that client'sparticular healthcare treatment plan. In one embodiment, an open accessenvironment can be provided through an IT platform to enable a jointdecision-making process between a healthcare recipient and his/herhealthcare provider(s) for the course of that healthcare treatment.

In another aspect, the methods of doing business coordinate phases of atraditional episodic delivery system. For example, health care data fromeach of the services 110-140 can be captured and made accessible, forexample, using the underlying information technology platform 150.Business methods implemented by the information technology platform 150can capture and archive disparate data from the services 110-140 and cannormalize the data to produce outcomes from a clinical, economic,clinical research and community service perspective for improvingstandards of practice. Whereas healthcare outcomes are conventionallyobtained from manually retrieved clinical and economic indicators, theoutcomes herein can be automatically processed using the businessmethods described herein.

In certain arrangements, but not herein limited too, the coordination ofthe human and health care services and delivery through the businessmethods can be implemented within a web-based platform; for example, anintranet or extranet platform, an education tool, a tele-healthmonitoring system, or a clinical research tool. Those skilled in the artcan appreciate that the web-based platform provides an integratedhealthcare service to improve the quality of life of a participant byconsolidating disparate service programs which would otherwise beunavailable as a single personalized health care information source tothe participant. The underlying business methods link services 110-140and consolidate the data for each respective service to enhancehealthcare, vocational, and social service delivery outcomes and healthcare provider protocols. Integration of the business methods forproviding a coordinated human and health care services and deliveryprogram can include numerous services other than 110-140 which arecontemplated herein.

Referring to FIG. 2, a coordinated service delivery network 200 forcoordinated health and human services management is shown. Thecoordinated service delivery network 200, can include an intakeassessment and recruitment module 210 for population stratification andrecruitment of clients having chronic disease or disability, a primaryintervention module 220 for developing an individual development planand for enacting action-learning through peer support team intervention,a secondary intervention module 230 for providing coordination ofservices through an information technology (IT) platform, and aninformation archive 240 to coordinate services for monitoring andtracking client progress. The coordinated service delivery network 200can further include a an Evaluation module 250 and a Policy module 260.The Evaluation module 250 can contain a Program Analysis and anIndividual Outcomes Study Development. Notably, the implementation ofthe coordinated health and human network 200 relies on the IndividualDevelopment Plan (IDP) 222, the Support Service Coordination Groups(Peer Support Teams) 224, and the Action Learning 226.

Referring to FIG. 3, the modules 210-260 of the coordinated servicedelivery network 200 are shown. In some embodiments within thecontemplated scope herein it may be useful to access the informationarchive 240 (i.e. web-base IT platform) for various purposes. One suchpurpose may be for evaluating client outcomes as shown in FIG. 2.Another such purpose may be for implementing policies based on anoutcome. Understandably, the information archive 240 provides variousnetwork configurations for interfacing and interacting with thecoordinated service delivery network 200.

In one embodiment, the information archive 240 can be an informationtechnology (IT) platform for sharing and archiving information. Forexample, one method of doing business implements a coordinated servicesdelivery that takes a holistic approach to providing healthcare,wellness, social and vocational services to participants, includingoverall community integration. Note, the primary intervention module 220and secondary intervention module 230 provide an environment wherein ateam of professionals and “third party” providers utilize ActionLearning 226 to maximize their capacity and ability to collaborate withone another. The center of the teams actions is the creation of the IDP222 that outlines the client's overall plan to realize his or her goaltowards of independence.

Understandably, creating an integrated development plan with theparticipants and/or their family is an integral aspect of the businessmethod. The IDP 222 represents a fulcrum in balancing the “goals” of theparticipant on one side and “results” of the program on the other. Theinformation archive 240 can measure and report on the outcome ofstrategies undertaken by the clients and the teams through periodicreviews processes. Understandably, one of the business methods ismeasuring and reporting the outcome of strategies. The informationarchive 240 allows for the capacity to collect long term clinical,behavior and compliance information to evaluate long term studyoutcomes. Understandably, one of the business methods is collecting longterm clinical, behavior and compliance information to evaluate long termstudy outcomes.

The connection of the pieces of the puzzle 100 in FIG. 1 can provide aseamless, efficient, and cost-effective integration of the services110-140 for supporting the coordinated service delivery network 200. Onebusiness method includes constructing a coordinated service deliverynetwork among stakeholders of the program using information technologyand team building with “Action Learning” principles as a primary tool tofacilitate the integration of services. Action-learning is a primarytool which allows clients and peer support teams to interact and learnfrom one another. In one aspect, a method of doing business consolidateshealthcare and wellness services, educational services by employingaction learning, vocational services such as employment networks, andsocial services. The business methods coordinate access to healthcare,social and vocational services for persons with chronic disease anddisabilities thereby facilitating community integration, and,accordingly, an improved quality-of-life for the client. The businessmethods take the client beyond his or her traditional role of being thepassive recipient of services to becoming an active partner in thedecision-making processes that can be required to effectively manage hisor her comprehensive personal service plan.

In one aspect, the coordinated service delivery network 200 is anevidence-based, population-based model that delivers health carerelevant services customized for a targeted population consistent withthe demographics and epidemiology of that population. The Communityhealthcare/vocational/advocacy workers can be placed at the core of theservice delivery model, relying upon the confidence building personalrelationships, trust and emotional support established by peer-to-peercounseling, to support care plan compliance and to provide socioeconomicsupport. The business methods can provide specific learning content fromperiodic peer support team meetings on an interactive basis versusdidactic learning. The coordinated service delivery network 200 canemploy business methods that monitor progress and provide feedback toprogram managers and program stakeholders. The coordinated servicedelivery network 200 can focus on the ultimate goal of improved qualityof life for clients, encompassing clinical, social, and vocationalmeasures and outcomes. The coordinated service delivery network 200 canprovide a central prescription drug benefit and counseling service, aswell as access to appropriate nutritionals based on indications of aclients particular health condition.

In yet another aspect, the coordinated service delivery network 200 cantarget Ticket to Work assignees to Vocational Rehabilitation. Thenetwork 200 can provide active recruitment of eligible Ticket holdersthat have activated their Ticket and have been assigned to a Division ofVocational Rehabilitation. The network 200 can assign a pool of eligibleTicket holders in accordance with the number of participant slotsavailable in intervention and control groups. The network 200 canprovide a support service coordination system that is consumer-drivenusing a peer supported “Action Learning” 226 approach to coordinate,advocate and manage services. The network 200 can provide a peersupported process of Action Learning 226 for interactive problem solvingto improve long term “Lifestyle” changes and promote consumerempowerment. The network 200 can provide a comprehensive and coordinatednetwork of support services, such as primary healthcare, communityintegration, job readiness and placement through an integrated servicenetwork. In one arrangement, the network 200 can provide partnershipwith state sponsored programs through an underlying network connectionto maximize all program outcomes. The network 200 can interface to a webbased IT platform can capture, analyze, and process program data topromote communication among all critical stakeholders.

Referring to FIG. 4, service domains under the coordinated health andhuman network 200 of FIGS. 2 and 3 are shown. The service domainsinclude a clinical services domain 232, an education services domain234, a community services domain 236, and a vocational services domain238. Embodiments of the invention are not herein limited to providingonly these service domains. In addition, all the modules in each domaindo not have to be a part of each program application. For example, awellness and prevention model application can be created from three ofthe domains excluding the employment domain. The domains and functionalmodules associated with each domain can employ business methods thataccommodate several program applications. In one aspect, but not hereinlimited to, the network 200 can employ business methods that offer aunique opportunity and research platform to conduct clinical researchfor chronic disease population among underserved, underinsured and/orminority populations.

The clinical services domain 232 can employ business methods thatinclude risk stratification, compliance monitoring, wellness/fitnessprograms, prescription drug and counseling programs, nutritional andsupplemental programs, home healthcare encounters, outpatient primarycare encounters, and inpatient encounters. The education services domain234 can employ business methods that include self-management education,advocacy training, continuing education training, micro-computertraining, and technical assistance. The community services domain 236can employ business methods that include housing services,transportation services, accessibility services, adaptive technologyservices, and recreation services. The vocational services domain 238can employ business methods that include job readiness training,mentorship and internship programs, networking development, resume andinterviewing skill development, and job listings and postings. Adescription of the four categories follow:

The clinical services domain 232 can employ business methods thatcoordinate clinical services through outpatient, wellness/exercise, homeand inpatient encounters. The clinical services domain 232 can employbusiness methods that are centered on prevention and wellness incombination with the Individual Development Plan 222. The clinicalservices domain 232 of the program can employ business methods thatcoordinate clinical services through outpatient, wellness/exercise,prescription drug services and counseling, home and inpatientencounters. Most program participants (i.e. clients) qualify for privatehealthcare benefits or public healthcare benefits including Medicare orMedicaid or dual eligibility. Each participant can expected to have orbe given the opportunity to select a primary care physician. Physicianscan share clinical information with the Program and portions of thisdata can be updated in the database. This data sharing can occur withthe consent of the client. This information can be part of the clientrecord or the Individual Development Plan. The basic clinical servicesthat are provided in the network can employ business methods thataccount for risk stratification, compliance monitoring, wellness/fitnessprograms, prescription drug & counseling programs, nutritional andsupplement programs, home healthcare encounters, outpatient primary careencounters, inpatient encounters

The educational services domain 234 can employ business methods thatteach clients skills such as problem solving and decision making forcoping with their chronic illness. The educational services domain 234can employ business methods that teach clients with chronic disease theskills and confidence they need to manage their disease on a daily basisand to manage the longstanding life impact of the disease throughprinciples of self management. For example, people with a chronicdisease having received basic disease-specific education are expected tomanage the disease for the rest of their lives. This can be the case forminorities and disenfranchised populations who do not have continuity ofhealthcare. Accordingly, peer support teams provide a forum forself-management education and advocacy training. The educationalservices domain 234 can employ business methods that provide preventioneducation for family members, or friends, of clients with chronicdisease and disability. Self management education is the responsibilityof all members of the peer support team. Customarily, the physician orprimary is responsible for informing the client on how to manage theirchronic illness. However, rarely will there be time in the averageclient encounter to adequately provide such instruction. The educationalservices domain 234 can employ business methods that provide a teamapproach including clinical experts, nursing and other disciplines toprovide client and family education.

The education services domain 234 can employ business methods thatpromote self-management education, advocacy training, continuingeducation training, micro-computer training, and technical assistance.The self-management education can be community-based which differs fromtraditional self-management education in several ways. First, it can bebased on problems identified by the participants, where needs driveprogram content. Second, program content focuses on imparting skillssuch as problem solving and decision making. A purpose of the educationis to prepare program participants to have the skills and confidence tomanage their disease on a daily basis, as well as to manage their liferoles and emotions. Judgment about the quality of the education can bebased on improvements in key health, functional, productivity andlifestyle outcomes. The outcomes may be both physiological andpsychological having a direct impact upon quality of life.

The community services domain 236 can employ business methods thatpromote housing services, transportation services, accessibilityservices, adaptive technology services, recreation services whichprovide activities for client's daily living. Understandably, thecommunity services are offerings available from the community to theclient to assist the client with their daily living. This can includephysical and occupational therapy, physical environment services andaccessibility training, and transportation accessibility, housingservices, transportation services, accessibility services, adaptivetechnology services, child care, and recreation services. Moreover,technical assistance by benefits and financial counselors can beprovided to train and assist clients to better navigate the variousreimbursement and payment systems for improving personal financialplanning. The community integration section employ business methods thatcan capture primarily employment information from vocationalassessments, including resumes, internship and mentorship opportunities,job postings and job retention data. In addition, it contains local andregional community services resources. Community services can becoordinated and/or facilitated through a Support Service Group (SSG)Manager through a respective Peer Support Team.

The outcome of these facilitated services can be based on the ability ofeach client to live and function independently and to successfullyre-integrate into his/her respective community, to the fullest extentpossible. The measure of these outcomes can be self-reported levels ofphysical activity, directed at increasing participants' ability toperform basic tasks of daily life, including participation incommunity-based activities. Community services within the IDP 222 may beunique with milestones that address both real and artificial barriers toemployment and community integration.

The vocational services domain 238 can employ business methods thatpromote job readiness training, mentorship and internship programs,networking development, resume and interviewing skill development, andjob listings and postings. Understandably, a primary outcome of theprogram is gainful employment facilitated by a coordinated continuum ofservices that provides job readiness training and community integrationservices. In one aspect, the program can employ business methods thatfacilitate and enhance employment opportunities for the programparticipants in partnership with divisions of vocational rehabilitationand associated employment network collaborators. Each participant canprepare for employment opportunities through the mechanism of a PeerSupport Team (PST), including: vocational assessments, job readinesstraining, job mentor ships and internships, employment referrals,follow-up and employment retention, though are not limited to these.Moreover, participants may also be trained and supported in learning howto identify and pursue their own employment opportunities.

The vocational services domain 238 can employ business methods thatprovide basic services including job readiness training,mentorship/internship programs, networking development, resume andinterviewing skill development, job listings & postings. Understandably,a primary outcome of the Program is to facilitate a coordinatedcontinuum of services for helping a client ensue gainful employmentopportunities. Business methods include organizing peer support teamshelp a client prepare for employment opportunities which include:vocational assessment, job readiness training, job mentorship,employment referrals, follow-up, and employment retention. In onearrangement, the program can employ business methods to collaboratedirectly with both public and private placement agencies to facilitateemployment. For example, a platform includes an employment section topost client resumes, and job postings that are actively recruited fromthe local community. The vocational services domain 238 can employbusiness methods that create a virtual job fair within the IT platform.Understandably, preliminary communication and information is exchangedwith potential employers using the IT platform.

Program participants' vocational and employment efforts can becoordinated with a provider such as a division of vocational resources(DVR) and/or an employer network (EN) to support their final employmentgoals. The coordinated health and human network 200 can employ businessmethods that promote for the collaboration with DVR and ENs to developpartnerships with local employers, business advisory councils and otherrelevant community providers in order to improve employment outcomes.These collaborations can also be developed to improve employer awarenessof employment for persons with disabilities. Within the vocationalservices domain, participants can be provided basic microcomputer skilltraining and computer access in a classroom environment.

For example, the skill training can promote each participant's jobreadiness skills with basic word processing, spread sheeting, databaseand communication skills. Additionally, it will give each participantthe ability to access their respective program files, input information,review calendar of program events and communicate with programstakeholders. The vocational services domain 238 can employ businessmethods that promote an employment section to post client resumes, aswell as job postings for providing active recruitment from the localcommunity. In one aspect, the vocational services domain 238 can employbusiness methods that create a virtual job fair. For example,preliminary communication and exchanges of information can even beexecuted over this platform with potential employers by the prospectiveemployee(s).

Embodiments of the invention also concern a program 500 (i.e. method)for coordinated health and human services delivery through aninformation technology (IT) platform. When describing the program 500,reference will be made to FIGS. 1-4. Moreover, the steps of the programare not limited to the particular order in which they are presented inFIG. 5. The program can also have a greater number of steps or a fewernumber of steps than those shown. The program 500 can include assessingand recruiting clients 510, developing an individual development planfor clients 520, supporting service groups and managing services forclients through action-learning and peer support team intervention 530,sharing and archiving information for monitoring and tracking clientprogress 540. In a first arrangement, the program 500 can furtherinclude delivering the services through an IT platform for providingon-line access 550, and analyzing and measuring the effectiveness of thecoordinated service delivery program 560 to provide healthcare,community integration, and employment services to the client. In asecond arrangement not shown, the program 500 can further includecollecting outcome performance indicators for evaluating them againstthose collected from a control group. The program 500 can also includeproviding policy implication recommendations.

In one embodiment, the program 500 can provide a consumerdriven/client-centered approach that involve the client as an activeteam member stressing self-determinant collaborative goal setting forimproving client-provider participation and interaction. In anotherembodiment, the program 500 can provide a service delivery extension totraditional medical and wellness care that links social and vocationalservices to facilitate community inclusion in addition to fundamentalclinical and economic goals. In another aspect, the program 500 can bedeployed within a special needs community such as SSDI and SSIbeneficiaries (or populations) for providing services to adisenfranchised, disabled, or minority populations at high risk forchronic disease and its co-morbidities, and consequent disabilities.

The program 500 can extend service delivery beyond traditional medicalcare to link community and vocational services thereby facilitatingcommunity inclusion in addition to fundamental clinical and economicgoals. The business methods of the program 500 can provideimplementation for a client-centered model improving uponclient-provider interactions by involving the client as an activeprogram team member and stressing client-centric collaborative goalsetting. The program 500 can apply principles of Action Learning as theunderlying process to promote behavior modification and lifestylechange. In this aspect, the methods of doing business can place peersupport teams at the core of the service delivery model, relying heavilyupon the personal relationships, trust factor and emotional supportestablished by peer-to-peer counseling, to IDP compliance to enhancegainful employment opportunities.

In one arrangement, the program 500 can be implemented through an ITplatform, which coordinates and maintains connectivity of services andoverall communication among program stakeholders. In practice, an ITplatform can implement the program 500 to provides seamless, efficient,and cost-effective facilitation of health care delivery features as oneimplementation example. Another implementation example can be anintranet or extranet platform. The IT platform can enable definitivedata capture to validate program premises by measuring and analyzingprogram indicators/metrics. Understandably, business methods includecapturing data and validating program premises. The business methodsunderlying the IT platform can allow for the development of a new anddifferent perspective on outcome development by combining data analysisresults from healthcare to community and vocational services allowingfor the opportunity to develop new cost/economic models. It should benoted that the program 500 can be implemented by various otherapplications which may or may not be.

In one application, the program 500 can combine a coordinated, holistic,consumer-directed care approach within an Employer Network, such as astate Vocational Rehabilitation Division. Business methods includepartnering with an Employer Network to maximize the support and servicesavailable and accessible to project participants. Understandably, thepartnership can increase a client's opportunities to increase theirindependence, productivity, and self-worth. Such partnerships can alsoincrease the research value or program potential for examining futurestatewide and nation wide policy issues. Business methods can includeexamining problems and recommending solutions considered from theperspectives of the client or individual, or providers such as theemployer networks or the funding agencies such as the SSA, Medicaid, andMedicare.

Referring to FIG. 5, the first method 510 of the program 500 is intakeassessment and recruitment of candidates. The intake assessment andrecruitment method collects long term clinical, behavioral, andcompliance information from clients to evaluate long term studyoutcomes. This can include analysis of demographic, employment history,prevalence of chronic disease and other health factors, utilization andother risk stratification factors for chronic disease and disability.Briefly, referring to FIG. 6 a flowchart for client intake evaluation isshown. At step 610, consumer focus groups can gather marketing data. Atstep 620, a primary pool of eligible ticket holders can be identified.At step 630, a database of the ticket eligible pool can be queried. Atstep 640, clients can be pre-screened for eligibility review. Notably, asecond pool 632 and associated database 634 can be queried to identifyother eligible candidates. At step 640, a call pre-screening can beconducted to interview identified candidates. At step 650, a controlgroup of candidates ineligible to participate is formed. At step 643,eligible candidates are screened to collect demographic, employment,health care data, and the like. At step 644, clients are evaluated forintake assessment. At step 646, a pool of recruited clients is enrolledin the program 500. At step 648, program initiation begins whereinclients go through a base line interview, an orientation, and areassigned to peer support teams. Clients not selected in the control poolare interviewed at step 652.

As a particular example of the intake assessment and recruitment method,a supporting method 700 for assessing and recruiting clients is shown inFIG. 7. The method 700 can also have a greater number of steps or afewer number of steps than those shown. At step 701, client manualrecords and client information from an electronic database 702 can bereviewed 703 to generate a client profile. This can include collectinglong term clinical, behavior, and compliance information from clientrecords. A client profile describes the health type characteristics fora candidate participant. At step 704, an inquiry can be sent to thedatabase 705 for identifying candidate clients. The inquiry can includeanalysis of demographic, employment history, prevalence of chronicdisease and other health factors, utilization and other riskstratification factors for chronic disease and disability. A profile ofclient qualification criteria with the support of all programstakeholders can be generated.

At step 706, the client can be subjected to a primary screening. Clientswho are not chosen 707 are encouraged to participate in the traditionalprograms. After the pre-screening process 708, data of selected clientscan be input 709 into the Program's database 710. The pre-screenedclients can then be interviewed 711 in person where they live, allowingdirect assessment of their needs and interest in participation. At step712, a secondary screen process can be conducted. Prospective clientswho are not chosen 713 are encouraged to participate in the traditionalprograms and are given recommendations if they wish to be consideredagain for the Program. The clients may be encouraged to participate inparts or selected modules of the Program, if available. The Programdatabase is updated 714, and the qualifying clients can receive programmaterials by mail and can be scheduled for a “face to face” interview715 for final screening 717. Final interviews are given, and qualifyingclients are finally selected, enrolled 722 in an orientation program720, and then assigned to a peer support team 723, with team membersusually geographically proximate in a neighborhood. Clients that are notchosen 718 or that drop out from the orientation are updated within theprogram database 719. Clients that are not chosen are encouraged toparticipate in a traditional program and are given recommendations ifthey wish to be considered again by the proposed Program

In one practical example, the intake assessment and recruitment module210 of FIG. 2 can be applied to recruit Ticket to Work beneficiaries.Understandably, the module 210 can include developing a profile ofclient qualification criteria for recruiting clients and receivingapproval and support from program stakeholders. Tickets to Workbeneficiaries, however, have been historically skeptical inparticipating. In general, eligible beneficiaries have had no interestin returning to work, and they can be highly distrustful of governmentprograms. Understandably, eligible beneficiaries do not want to riskloss of their existing benefits and are not interested in risking lossof this safety net once in place. Eligible beneficiaries consider returnto the workforce, if physically and mentally able, and perceived assignificant gain and life improvement. Their mental outlook can directlyimpact the ability the program's ability to recruit these populations.The co-morbidity of depression is often present, and some havelifestyles, including diet, that work against their health and sense ofgeneral well being. Existing services are difficult to access and arecompartmentalized and fragmented, and therefore difficult for theeligible beneficiary to navigate.

Very few of those beneficiaries recruited have actually returned to theworkforce. Accordingly, the program 500 includes a recruiting strategywithin the intake assessment and recruitment module 210 of FIG. 2 thatovercomes these barriers. The business method strategy includesrecruiting upbeat and non-bureaucratic individuals, focusing on buildingthe level of trust in dealing with program staff, assessing what isimpacting the lives of those being recruited, planning to thesensitivity of challenges faced by counselors in working with thebeneficiaries, and providing marketing strategies that are the productof joint deliberation between vocational rehabilitative teams andmanagers. The intake assessment and recruitment module 210 includesbusiness methods that identify which beneficiaries are selected asparticipants for the coordinated health and human services deliveryprogram.

Referring back to FIG. 5, the second method 520 of the program 500 isprimary intervention wherein an individual development plan (IDP) can bedeveloped, peer support teams can be formed, and action learning can beapplied. Understandably, the method 520 includes developing anindividual development plan for clients, forming peer support teams, andapplying principles of action learning. Notably, the IDP is thedistillation of the overall plan of the client's goals and aspirationsbenchmarked against the real possibilities of achieving the documentedpersonal goals. In essence, the IDP is the “fulcrum” upon which therealization of program goals rests. Action-learning is the overallclimate by which the IDP is processed. The combination of the IDP, asthe critical client tool or plan, with action-learning, as the modelprocess with its interactive, team-building, empowering and selfdeterminant qualities, and finally the secure use of the Internet tocommunicate and share information make a unique service delivery program500.

Referring back to FIG. 2, the primary intervention module 220 caninclude business methods which help each client create an IndividualDevelopment Plan (IDP) 222 in concert with family members, peers, andother program stakeholders. The IDP 222 can be a multifaceted documentthat provides the clinical background and life history of the client.For example, the IDP 222 can contain education, training received,family information, and employment history of the client, but is notlimited to these. The IDP 222 can include demographic information,health status information, community information, social servicesinformation, vocational information, and employment information. The IDP222 can be used as a roadmap to balance the goals of the client with theprogram results.

The IDP 222 is the client's service management record. Most importantly,it is the documentation and progress record of the program goals thatthe client hopes to achieve. Participants lay the ground work for theirIDP 222 by determining goals that they choose to pursue, whether theyrelate to health, fitness, self-confidence building, employment or otherareas. The IDP 222 becomes the prime vehicle for tracking progress andreviewing indices that relate to improved health and general well-being.It is used to monitor progress in pursuing employment related goals.Notably, the information generated can be held in strict confidence.Families can be encouraged to be a part of the process, subject to theapproval of the participant.

The primary intervention method 220 can coordinate the exchange ofinformation between a client and a peer support team 224 composed of agroup of individuals that together help the client with communityintegration and re-employment. The client and the peer support teamparticipants learn from each other through action learning.Action-learning is a primary tool within the primary intervention modulewhich allows clients and peer support teams to interact and learn fromone another. The monitoring and implementation of the individual goalswithin the IDP 222 includes the use of these peer support mechanismswhich is central to the primary intervention module 220. As part ofAction Learning 226, the process focuses on the use of Peer SupportTeams and Peer Support Circles which includes teams of professionals andthird party providers such as specialty physicians or governmentprograms to help define client qualification criteria. The primaryintervention method 220 provides an environment by which interactiveinformation can be communicated, shared, and archived.

Notably, the coordinated human and health service delivery program 500sets out to promote lasting behavioral changes in the life of theparticipants, whether it is greater discipline in managing medications,better diet, weight control, or other health indicators. The deliveryprogram relies on Peer Support as the foundation. Participants areencouraged to adopt new positive ways of thinking. Because the programis self directed by participants in terms of taking control of their ownlives, the degree of buy in can greatly exceed traditional governmentprograms that flow from a less empowering authoritarian model. Takingaction is not an end all. Once action is taken the individual needs toreflect on what has been learned, and how to sustain the changeinvolved. Action Learning requires a balance between action andreflection if deep learning, of the kind that can lead to behavioralchange, is to occur. A Learning coach facilitates this balance.Participants share what has been learned with other members of a peersupport team (PST) and a peer support coach (PSC).

Referring to FIG. 8, a hierarchy of program stakeholders, participants,and clients is shown. Within each support service group 858, one clientdelegate can be chosen by each peer support team to serve as a delegateto serve on an Action-learning support service group team with onelearning coach 856 from that support service group acting asfacilitator. The peer support team 854 can be further divided into threeworking Action-learning groups or peer support circles (PSCs) 852 offive members each. Embodiments of the invention are not herein limitedto having only three working groups, the PST can have more than or fewerthan this number. This team can discuss progress achieved within theirrespective support service group and provide feedback to promoteachievement of client and peer support team goals. Further, these teamscan participate in discussions with both provider and employment serviceteams to enhance client provider and employer relationships. Peersupport circles within the hierarchy may have no designated leaders, andparticipants determine priorities and areas of focus by the help of alearning coach. The coach can also serve as a resource for identifyingagencies or programs that can provide support. Together, the peersupport team and client employ action-learning principles.

Support service managers within a peer support team can coordinate orfacilitate the availability of the community services to the client inorder to maximize vocational and quality of life outcomes. For example,an outcome of these facilitated services can be measured as the abilityof each client to live and function independently and to successfullyre-integrate into his/her respective community, to the fullest extentpossible. The measure of these outcomes will be self-reported levels ofphysical activity, directed at increasing clients' ability to performbasic tasks of daily life, including participation in community-basedactivities.

In one aspect, the organization chart 800 represents the program supportservice coordination for the clinical services domain 232. The primaryunit of service within this organization chart 800 is the SupportService Group 858. The organization chart 800 includes at least one PSC852 and one PST 854. At the top of the organization's structure is theSupport Service Group Coordinator (SSGC), who is the principalgatekeeper of the Support Service Coordination Group (SSCG) 858. TheSSGC 858 supports nine PSTs 854 (approximately 135 participants), andoversees three Learning Coaches 856. This person (857) is the primarycoordinator of all program services and resources for those participantsin the SSCG 858. The Learning Coach reinforces action orientation byrecognizing the achievement of individual members through PSTcelebrations of success. Progress is also reinforced by actively usingthe IDP as a vehicle for counseling individual PST members. This canlead to amendment of the IDP.

The three Learning Coaches 856 in the SSCG 858 have reportingresponsibilities to the Support Service Group Coordinator (SSGC). TheLearning Coach's 856 responsibility is to facilitate three Peer SupportTeams (PST) 854 (approximately 20 persons each), as well as the threePeer Support Circles (PSC) 852 (approximately 7 persons each) under eachPST. The Peer Support Teams (PST) 854 provide the centerpiece for allprocesses that occur in the program 500. PST's 854 are guided by theprinciples of Action Learning. Each PST (12 to 18 members) 854 can becomprised of three Peer Support Circles (PSC) 852 of four to six memberseach.

The PSCs 852 operate as Action Learning teams which corresponds to thedivision where the Individual Development Plans (IDP) begin to emergethrough the process of mutual collaboration and support. The basictenets of Action Learning are based on the simple principle of placingpeople in a safe and trusting environment where they can learn from andwith each other. Action Learning provides a confidential and secureenvironment for interactive dialogue and problem solving. The LearningCoach (LC) 856 does not act as a leader of the team per se, but ratherguides the process. The LC 856 facilitates the PST 854 and PSC 852activities, and works with each participant in developing and managingtheir IDP. Support Service Coordination is solely managed within theSupport Service Group. Service coordination is primarily based on ActionLearning driven interactive problem solving whereas participants withineach PST or PSC identify problems specific to their respective needs.This process may result in a service referral if the issue cannot beresolved within the PST or PSC. All referrals are made through theLearning Coaches to the Support Service Group Coordinator forvalidation. The referrals are then ultimately made by the SSGC to aSupport Service Network (SSN).

Referring to FIG. 9 a support service coordination flow chart 900 isshown. The flow chart 900 identifies the IDP within the center of a peersupport network. At step 901, an IDP 222 can be created for a client. Atstep 902, a peer support team 902 comprising a peer support circles 903can be assigned to work with the client. At step 905 peer supportinvolvement with the client can help the client identify and resolvehealth care issues. At step 906, a referral request for considerationcan be made. At step 907, problems referred from the PSCs can beassigned to a learning coach 908. The learning coach can refer thedecision 909 to a support service group coordinator 910. The servicegroup coordinator 910 can interact directly with the client and the peersupport team 911. Accordingly, the support service group coordinator canrefer 912 the service decision to the support service network 913.Notably, the support service network can include the clinical,community, and vocational service domains 232-236. The support servicenetwork 913 can provide self management education and problem solvingskills to the client through coordinated delivery of services 914.

With the assistance of the Learning Coach, the Support Service GroupCoordinator serves as the primary gatekeeper of client servicecoordination. One responsibility of the Support Service GroupCoordinator can be to identify facilities, coordinate transportation,schedule childcare, and track client referrals via a web based platform.By monitoring progress versus IDP's across the various PST's, themanager is able to capture critical data for evaluation purposes. Thismanager also determines the optimal setting for PST meetings, includingcommunity settings, such as churches, community centers, health clubsand schools, making sure that the facilities provide lockers and showerfacilities to support the fitness component of what occurs as a part ofeach PST meeting. During the biweekly PST meetings, clinical functionaldata is collected and a learning delivery process of self-managementeducation and peer support counseling is provided. In this forum,clinical and community services are also provided, including benefitscounseling, vocational assessments and job readiness services. Jobmentorships, internships and job interviews are coordinated through thePST process and Support Service Group Coordinator in concert with theState Division of Vocational Rehabilitation (DVR) organization and othercommunity stakeholders.

Support Service Group Coordinators work closely with the learningcoaches and their respective peer support teams to regularly monitorboth self-tested and laboratory tested diagnostics and their socialperformance measurements or indicators. These managers are responsiblefor monitoring data and determining, in collaboration with the learningcoach, how best to support each client, including clinical follow-up,and educational, community or vocational interventions that are bestfitted to the IDP. The Support Service Group Coordinator is alsoresponsible for making sure that all participant data is updated anddocumented on-line.

In addition to the Peer Support Circle (PSC) 852 within the PST's 854,each Support Service Management Group 858 can have an overall ActionLearning team, called a Hybrid Action Learning Team. One “delegate” fromeach PST 854, democratically “elected” by the PST membership, can serveon this team. This team serves to synthesize and communicate the viewsand recommendations of all nine PSTs 854 in each pilot location. TheHybrid Action Learning Team provides feedback to the program managers onhow the program can be further refined from a consumer perspective. Thisis another example of the client as the principal focus in this program,a strategy that fosters engagement and buy-in through participation inthe seminal processes that guide the delivery systems. In this respectit can underwrite self-determination, empowerment, independence andself-governance. PST delegates can serve as liaisons with their PST'smembership for providing real time feedback on discussion of issues,recommendations, and decisions reached. Delegates to the Hybrid ActionLearning Teams can also be invited to serve as assistants to theLearning Coaches 856 in maintaining systematic contact with those PSCmembers who leave the PST 854, either through employment or for otherreasons. These delegates can be seen as potential future LearningCoaches 856 based on the leadership traits they demonstrated in beingelected as delegates to the Hybrid Action Learning Team 851 and theirwillingness to accept such service.

In one example, a Support Service Group Coordinator can be a nursepractitioner who is the primary gatekeeper for coordinating allparticipant services referred to the program. For example, the nursepractitioner can be a SSGC who is responsible for monitoring andreviewing clinical indicators or any data reported as “flags”. The nursepractitioner can try to resolve or make the appropriate clinicalreferrals to the respective care physician. A nurse practitioner candiagnose and prescribe medications, as well as make referrals toappropriate specialists, if necessary; the position in one respect isproviding a primary care role.

A team approach can be implemented with the SSGC as the team leader,together with the participants and their family, the Learning Coaches,clinical professionals, as well as other disciplines review clinical andcommunity data to assist in IDP development and assessment. Clinicalexperts may provide part of the self-management curriculum, although allteam members are involved in the self-management education process. Aspart of self-management education (234), the client can be instructed tomonitor chronic disease indicators. These indicators can be tracked andarchived within an IT platform and supervised by the Support ServiceGroup Coordinator. Monitoring of such indicators can be a significantfactor in complying with the IDP (222). Compliance with the clinicalmodule of the IDP (222) may prevent or reduce acute healthcareencounters, significantly reduce healthcare costs and enhance employmentopportunities. Clinical indicators can be monitored during the weeklyPST meeting, and documented by entries in daily “Learning Logs”, or viatelephone monitoring. Acute incidences can be reviewed by the SSGC whomay be responsible to resolve all acute and chronic problems eitherinternally or by referral to the primary care or specialty physician.

Returning back to the program 500 of FIG. 5, the third method 530 issecondary intervention wherein service groups and management of servicescan be supported through principles of action learning. Understandably,the business method 520 includes supporting service groups and managingservices for clients through action-learning and peer support teamintervention. The program delivery, from clinical services toself-management and community services, can be orchestrated by amulti-disciplinary network of providers including an empowered clientthat shares in the decision-making process. The Program Team iscomprised of all the main stakeholders from the Support Service GroupCoordinator, physician, health educator, dietician, exercisephysiologist, Learning Coach, vocational counselor, benefits counselor,etc. Productive interactions between the client and the provider teamsare enhanced by an empowered client, evidence-based practice guidelines,individual development plan (IDP), and access to clinical and employmentdata.

The Support Service Network or the continuum of services and resourcesincorporates four main service activity areas or domains which in oneembodiment may be integrated by an IT platform 150 illustrated inFIG. 1. These services are monitored on-line by the Support ServiceCoordinators. In one aspect, the IT platform 150 facilitates access toall the service data generated by the Program team, as well all providerstakeholders. The IT platform 150 can integrate the primary interventionmodule 220 and the secondary intervention module 230. For example, thesecondary intervention module 230 of FIG. 2 can include a clinicalservices domain 232, an education services domain 234, a communityservices domain 236, and a vocational services domain 238. The clinicalservices domain 232 can include business methods that monitor chronicdisease indicators captured during peer support team meetings. Theindicators can be archived in a database for complying with the IDP(222). The education services domain 234 can include business methodsthat provide preventative education for family members of clients withchronic disease and disability. The community services domain 236 caninclude business methods that support active daily living of clients forovercoming employment and community integration barriers. The vocationalservices domain 238 can include business methods that facilitate acoordinated continuum of services for providing the client with gainfulemployment opportunities.

The environment provided by the continuum of services (232-238) guidesthe client through program modules (510-560) for building theircapability to live a full life and find meaningful employment. In orderto produce the environment, peer support teams (PST) are organized toenact principles of action-learning to achieve both individualdevelopment plan (IDP) and team goals. The secondary intervention module230 can include business methods that engage peer support teams (PST) touse the principles of Action-learning to meet both individual (IDP) andteam goals. Understandably, action-learning facilitates the peer supportteam intervention based on the premise that people placed togetherwithin an environment can learn from and with each other.Understandably, participants interweave action with reflection inlearning how to better handle various aspects of their lives whichelevates their chance of gainful employment.

For example, referring back to FIG. 2, the clinical services domain 232can include business methods that collect, archive and analyze mostclinical encounters, as well as clinical indicator information capturedfrom client diaries and PST clinical data collection. For example, theunderlying IT platform (150) of the coordinated health and humanservices delivery network (200) can provide the necessary connectivityinternally between the PSTs (854), as well as externally to thecommunity service providers or Support Service Network. The underlyingIT platform can also provide access to critical resources to allstakeholders including the program participants. The program outcomescan be considered the responsibility of all members of the PST (854).The PST (854) can provide the basic forum for self-management education,advocacy training and overall problem solving. The program can sustainthe PST (854) and basic peer support long term as the PST (854)continues during program follow-up and is encouraged to survive beyondthe length of the formal program.

Referring back to FIG. 5, the fourth method 540 of the program 500 issharing and archiving information for monitoring and tracking clientprogress. Recall, an IT platform (150) can unify the clinical servicesdomain 232, education services domain 234, community services domain236, and vocational services domain 238. Business methods includemonitoring on-line by the Support Service Managers and the PST coachesdescribed in FIG. 8. In one embodiment, such monitoring can be providedthrough an IT platform 150 as shown in FIG. 10. The IT platform 150opens access to the service data generated by the program team and otherstakeholders though the application of the business methods underlyingthe IT platform 150.

In one aspect, but not herein limited, the coordinated human and healthcare services and delivery program helps clients and participants managechronic disease through applied clinical research programs via anInformation Technology (IT) platform 1000. The IT platform 1000 can be avisual tool available on the internet and accessible to clients, theirsupport team, and program shareholders. The IT platform 1000 can deploya continuum of services within a collaborative network environment thatcan be monitored by the program shareholders to generate evidence-basedhealthcare outcomes and protocols for effectively managing chronicdisease and disability care. The IT platform 1000 can capture andanalyze a client's health care data according to current clinicalpractice protocols. The IT platform 1000 can implement a health caredelivery system based on Action Learning principles that coordinateservices to enhance gainful employment by fostering self determinationthrough “peer support” teams and multidisciplinary private/publicpartnerships which promote the capacity, quality and improvedsustainability of healthcare, community service and meaningfulemployment opportunities. The IT platform 1000 can collect, consolidateand analyze data during the progress of continued and monitoredparticipant health care. This information can be included within the ITplatform 1000 of community-based social and vocational services forguiding and helping the client seek gainful employment and communityintegration.

The platform 1000 can employ business methods to capture, archive,analyze, and disseminate data, and facilitate or integrate stakeholdercommunication. In general it provides an intranet platform for internalusers that include employees, consultants and participants. The ITplatform 1000 consolidates data from various information sources thatcould otherwise remain hidden inside isolated systems, available only todata management staff, and presents the data to all appropriate usersfrom all or most service points in a seamless and user-friendly fashion.The IT platform 1000 coordinates the continuum of services, monitors andtracks client progress by case managers (and other projectprofessionals), develops critical outcomes reports, and ensures optimaltreatment and use of program funds. The platform (1000) can containvarious algorithms that generate critical outcomes reports and archiveinformation in a data warehouse.

For example, referring to FIG. 11, an outcome report 1100 is shownthough section headings, entries, and components of the report 1100 areonly shown for illustration. Embodiments of the invention hereincontemplate various component arrangements and presentation formats andare not limited to those shown in FIG. 11. Understandably, the outcomereports allow for case or care management results which is a significantfunction of the platform, in that clients are strictly followed for careplan compliance and for tracking plan outcomes. The IT platform 1000 canbe a proprietary program that logistically coordinates the complexcontinuum of services (232-238) including the monitoring and tracking ofclient progress by Support Service Group Coordinators (SSGC) andLearning Coaches, or other project professionals. The IT platform 1000can also provide secure interactive communication and access toproprietary program information.

The information technology platform (150) supporting the IT platform1000 can comprise both public and private services. The public servicescan include: 1) general program marketing information, 2) generale-mail, 2) calendar, 3) discussion groups and forums and 4) general jobplacement information. The private section of the platform is secure andprivate, and can be divided into two main applications. The firstapplication contains the IDP or participant record including theclinical registry and self-management data. The second applicationcontains community and employment service information.

Referring back to FIG. 5, the fifth method 550 of the program 500 is thedelivery process wherein services can be delivered, for example, throughan IT platform, for providing on-line access to the client'spersonalized health care program. The delivery process guides the clientthrough program phases to build their capability to live a full life andfind meaningful employment using principles of Action Learning. Theprogram delivery, from clinical services to self-management andcommunity services, is orchestrated by a multi-disciplinary team ofexperts using Action Learning. The Action learning aspect of the programdelivery allows the client to take equal part in the decision-makingprocess of the client's health care plan. Notably, the Program team iscomprised of all the main stakeholders including the primary carephysician, health educator, dietician, physical therapist, exercisephysiologist, support service manager, peer support team coach,vocational counselor, and benefits counselor. In practice, the deliveryprocess provides productive interactions between the client and theprovider teams. These interactions are enhanced by an empowered client,evidenced-based practice guidelines, individual development plan (IDP),and access to clinical and employment data.

For example, referring back to FIG. 2, the delivery process module 250collects clinical and functional data during PST meetings. The deliveryprocess module 250 provides learning delivery process of self-managementeducation and peer support counseling. Within this forum, the deliveryprocess module 250 coordinates clinical and community services andprovides benefit counseling, vocational assessment, and job readinessservices as part of the IDP (222). Job mentorship's, internships andinterviews are coordinated through the PST (854) and Support ServiceManager and with other community stakeholders actively involved in theprogram delivery process.

Referring back to FIG. 5, the sixth method 560 of the program 500 is theevaluation module wherein the effectiveness of the coordinated servicedelivery program to provide healthcare, community integration, andemployment services can be analyzed and measured. For example, referringback to FIG. 2, the evaluation module 260 can capture, measure, andanalyze program indicators/metrics to validate merits of the programdeployment. For example, the evaluation module 260 can evaluate outcomeperformance indicators collected from the program such as those fromresearch or intervention group dialogues against outcome performanceindicators collected from a control group such as external control. Theevaluation module 260 measures outcome performance collected at theconclusion of client participation with those collected during screeningand enrollment, the baseline or internal control. This allows theprogram shareholders to monitor, track, and adjust the services withinthe program while assessing program performance. For example, uponcompletion of the program, a client's community integration factors orre-employment statistics are used to determine the program impact.

Outcome performance indicators collected from the intervention group canbe evaluated against those collected from the control group (externalcontrol). Measures collected at the conclusion of client participationcan be compared with those collected during screening and enrollment,which forms the baseline and provides an internal control mechanism. Theprogram can be standardized on specific clinical, social/behavioral andeconomic indicators or metrics to measure and analyze overall programand individual client performance using validated instruments. Theevaluation design comprises: 1) existing instruments, 2) aself-evaluation approach, 3) clinical, process quality of life andeconomic indicators, and 4) descriptive consumer and serviceinformation. The evaluation data can be collected on an ongoing basis,cataloged and organized to conform to the capabilities and potential ofthe IT platform and interactively analyzed for feedback. Furthermore,results of the evaluation can be presented in an economic frame work.Quantitative and qualitative measurements can be analyzed forsignificant changes and other descriptive statistics.

For example, primary evaluation measures can be based on comparisons toan external control (like-peers) to specifically measure progress (˜12months post enrollment) towards achieving employment goals. Proactivemarketing and recruitment can be evaluated to assess the success of therecruitment model. As another example, secondary evaluation measures canbe based on comparisons to the internal control to measure progresstowards achieving personal/healthcare goals twelve months into theprogram relative to baseline (IDP). Participant satisfaction can also beassessed.

In another aspect, policy recommendations can be developed. This caninclude monitoring and analyzing policy implications arising from theenactment of the program. A team of nationally recognized health anddisability policy analysts can be put together to review findings, makerecommendations resulting from the program, and provide policyimplications for review by appropriate federal agencies. The results andrecommendations should prove to be valuable for creating policies andguidelines that will assist individuals in finding and maintainingemployment while not jeopardizing their health benefits and/or otherfederal benefits they may be receiving.

In one aspect, a Policy review can be developed to encompass regulatoryand legislative matters involving SSA and other proposal related FederalAgencies, the US Congress, proposal-related state agencies andlegislatures. A data analysis can also be conducted to focus on howpolicy alternatives will impact disability and provider organizations.Observations can be made from a retrospective as well as a prospectivepolicy perspective in view of program findings. Notably, SSA hasincluded policy implications in its annual reports to Congress, as ithas been called upon by Congress to address policy issues through itsResearch and Demonstration grants program. Accordingly, the policyrecommendations provided by the program may be helpful to SSA in bothits legislative and regulatory agenda.

For example, the program can produce findings that have relevance toexamining emerging policy implications for the Ticket to Work program.Accordingly, it can be envisioned that individuals selected toparticipate in the program and that complete the program will haveimproved job readiness and interviewing skills, improved management anddecision-making skills regarding their health options and health status,and have increased their natural circle of community supports andservices.

Recommendations can focus on, but are not herein limited to:

1. Regulatory—such as SSA's Ticket to Work regulations (proposedregulations are currently circulating for comment); benefits counselingand disability determinations regulations; HHS′ Medicaid Buy-in andother programs; RSA regulations and program guidelines for statevocational rehabilitation agencies and regarding supported employment,Randolph-Sheppard program; and, DOL's One-Stop Program regulations; theJavits-Wagner-O'Day (JWOD) Act program; and

2. Legislative—such as program consolidations and/or coordination; newfunding authorizations; reports by any oversight and investigativecommittees; new research and demonstration programs; new proposalsinvolving employment incentives; and clearer, more directedrelationships between the vocational and medical/health communities andprograms, to name a few. With less than 1% of these recipients currentlyreturning to the workforce, any demonstrable increase in individualsfinding and maintaining employment will be deemed significant in termsof costs as well as reaching the original intended goal of theTicket—successfully weaning people off of benefits by virtue of placingthem back into the job market. Through the use of a control group thatis similar to program participants with the exception of ourinterventions (the project itself), we may also examine findings thatcan suggest which current policies/practices in place now may actuallybe barriers to entry into the workforce.

The policy recommendation analysis can address identified fundamentaland significant barriers to employment. This can include, but is notlimited to: Psychological impact of the disability process, Physicalimpact of delayed access to health care, Lack of access to training andemployment services, Premature loss of benefits, Loss of ongoingemployment supports, DI cash cliff and SSI asset limits, Job loss anddifficulty of reinstatement, and Work-related overpayments.

Referring to FIG. 12, a client flow-chart 1200 for a coordinated servicedelivery management is shown. Notably, the client flow-chart 1200illustrates the importance of the two milestone events: the creation ofthe IDP 222 and the program services 224 which includes self managementeducation and case management that occurs within the peer support teams.Referring back to FIG. 2, the IDP 222 and the Peer Support Teams areprimary components for enacting principles of action learning. Theclient flow-chart 1200 illustrates population stratification 1210 whichcan include demographic data and diagnostic data as input to thecoordinated service delivery management program. Business methodsdeployed within the population stratification 1210 can include assessingrisk factors 1212. The risk factors can be assessed through clinicaldata and/or health maintenance data 1213. The risk factors 1212 can becarried forward to a primary care encounter 1220. The primary careencounter 1220 can diagnose chronic disease and enter health care datainto the IDP 222. A chronic disease diagnosis can lead to an inpatientcare encounter 1230. In one arrangement, information gathered from theinpatient encounter 1230 can be provided to a technology platform 150for presentation. The IDP 222 can be implemented with the participantthough the help of support services, group coordinators, and nursepractitioners as discussed in FIG. 8. The IDP (222) can includepsycho-social behavior data and personal compliance data as input whileproviding access to demographic data and clinical data 1232. Data can becaptured at baseline and at several intervals during the course ofprimary care encounter. Notably, the peer support teams (224) provideself-management training, action learning, and case management asdiscussed in FIGS. 2 and 8. Peer support team involvement can requireinput and access to demographic data, clinical data, psycho-socialbehavior data, health maintenance data, and scheduling data 1250. Peersupport team involvement can provide flags for clinical outliers,social/behavioral outliers, follow-up action appointments, and clienttracking 1250. Peer support team intervention can include servicereferral 1233 through services 232-238: community service, vocationalservice, and educational services in conjunction with self managementservices. Notably, health maintenance data, compliance data, exercisedata, and diet data 1213 identified during the action-learning can beprovided as information through an information technology platform 150.

A business method for coordinated human and health services delivery hasbeen provided. Notably, there are features of the services deliverymodel that emphasize distinguishing features over current health careservice practices. The model operates within a delineated community (orpopulation), providing services to clients at high risk for chronicdisease and its co-morbidities, and consequent disabilities. The modelfocuses on the overarching goal of improved quality of life for clients,encompassing clinical, social, and vocational measures and outcomes. Themodel extends service delivery beyond traditional medical care to linkcommunity and vocational services, facilitating community inclusion inaddition to fundamental clinical and economic goals. The model is anevidence-based, population-based model that delivers culturally-relevantservices customized for minority, underserved and underinsuredcommunities with its particular demographic requirements. The model isclient-centered improving upon client-provider interactions by involvingthe client and family members as active program team members andstressing client-centric collaborative goal setting by creating acomprehensive but dynamic care plan, namely an Individual DevelopmentPlan or IDP.

In one aspect, the model uses a total systems approach, integrating acomprehensive set of healthcare, vocational, community integration andeducation services. The model creates and establishes this “SystemsApproach” based on collaborations and close partnerships between programstakeholders, providers including consumers and their families. Anetwork of providers is instituted for such services that is coordinatedby the IT system but is facilitated by a Peer Support Team process andthe case manager which is specifically tailored for those with chronicdisease and disabilities.

In particular, the model uses Action Learning principles which are theunderlying process to promote behavior modification and lifestyle changeand which places peer support teams at the core of its service deliverymodel, relying heavily upon the personal relationships, trust factor andemotional support established by peer-to-peer counseling, to IDPcompliance and to enhance social service and gainful employmentopportunities. The model is a new and unique system of case managementusing a peer supported, Action Learning approach to empower clients toproblem solving their respective service and reimbursement issues withpeers and case managers which is a new bottom up approach. The modeluses Action Learning to drive a peer support system that empowersclients through customized self management education and problem solvinghow to self-determine how to improve their health, communityintegration, employment readiness, financial well being and overallquality of life issues. The model coordinates all system components by aweb based platform that broadly shares and integrates information acrossthe full spectrum of service providers, while at the same time honoringmatters of privacy and the requirements of a HIPPA compliant data base.

In one embodiment all program modules and stakeholder are unified by anIT platform, coordinating and maintaining connectivity of services andoverall communication among all program stakeholders and enablingdefinitive data capture to validate program premises by measuring andanalyzing program indicators/metrics. The IT platform provides thenecessary tools and suitable media for customized data collection andcapture, analysis, archiving, communication and information sharingamong the program stakeholders in a secure compliant IT platform. The ITplatform allows for the development of a new and different perspectiveon outcome development by combining data analysis results fromhealthcare to community and vocational services allowing for theopportunity to develop new cost/economic models.

In one aspect, the model institutes overall system linkages that areestablished to encompass local, state and federal systems in assuringseamless delivery, all indexed to a common client centric approach(e.g., Florida DVR and CSAVR at the national level or linkages toTrinidad and Tobago National IT Healthcare System). The model provides adistinctive management architecture, from the standpoint of processes,systems integration and IT. It is a holistic architecture thatsuperintends IT alone. The model provides for active recruitment ofeligible clients through the application and implementation of ProactiveIntake and Assessment or Stratification processes. The model promotespersonal accountability through the development of IDP and selfmanagement education, utilizing action learning and peer support teamprinciples to promote self determination, advocacy, gainful employmentand independence.

In one arrangement, the model is developed and implemented in phasesconsisting of primary and secondary intervention strategies. Primaryinterventions are IDP-based; focusing on the individual beneficiary,while secondary interventions are system-based provisions, includingclinical, educational, community, vocational services and benefitcounseling. The model can be streamlined for accountability through amechanism of evaluation for the individual participant and for thesystem as a whole. The model allows for the development on continuousquality improvement measures through analysis of outcomes. These outcomemeasures can also develop into policy recommendations. In one aspect,system evaluations focus on both short and long term achievements ofpredetermined measurable outcomes which can include but are not limitedto: Efficacy of recruitment, Attainment of IDP goals (as a jointresponsibility of the participant and the system), Clinical goalsoutcome, Job readiness and actual placements, Assessment of participantsatisfaction, and Quality of Life measures.

Where applicable, the present embodiments can be realized in hardware,software or a combination of hardware and software. Any kind of computersystem or other apparatus adapted for carrying out the methods describedherein are suitable. A typical combination of hardware and software canbe a communications device with a computer program that, when beingloaded and executed, can control the communications device such that itcarries out the methods described herein. Portions of the present methodand system may also be embedded in a computer program product, whichcomprises all the features enabling the implementation of the methodsdescribed herein and which when loaded in a computer system, is able tocarry out these methods.

While the preferred embodiments of the invention have been illustratedand described, it will be clear that the embodiments of the invention isnot so limited. Numerous modifications, changes, variations,substitutions and equivalents will occur to those skilled in the artwithout departing from the spirit and scope of the present embodimentsof the invention as defined by the appended claims.

1) A business method of coordinated health and human services anddelivery comprising: providing services to clients at high risk forchronic disease including co-morbidities and consequent disabilitiesassociated with said chronic disease; linking community and vocationalservices for facilitating community inclusion to supplement fundamentalclinical and economic goals; creating a comprehensive and dynamicindividual development plan to involve said client and family members asactive program team members for stressing client-centric collaborativegoal setting; and applying action learning to promote behaviormodification and lifestyle change. 2) The business method of claim 1,wherein said providing services includes delivering culturally-relevantservices customized for minority, underserved, and underinsuredcommunities having particular demographic requirements. 3) The businessmethod of claim 1, wherein said linking includes focusing on reach-outgoals of improved quality of life of said clients by encompassingclinical, social, and vocational measures and outcomes; and integratinga comprehensive set of healthcare, vocational, community integration andeducation services. 4) The business method of claim 1, furthercomprising coordinating and maintaining connectivity of said servicesand overall communication among program stakeholders; and providingtools and suitable media for customized data collection and capture,analysis, archiving, communication and information sharing of saidservices and communication. 5) The business method of claim 4, furthercomprising: measuring and analyzing outcomes of said services and saidindividual development plan by monitoring indicators and metrics forproviding continuous quality improvement measures; and validating saidservices and said individual development plan premises in view of saiddata measuring and analyzing. 6) The business method of claim 5, furthercomprising combining data analysis results of said services and saidindividual development plan for developing new cost economic models. 7)The business method of claim 1, wherein said linking further includeslinking local, state, and federal systems for providing seamlessdelivery of services. 8) The business method of claim 1, furthercomprising placing peer support teams at the core of a service deliverymodel for providing a coordinated management architecture. 9) Thebusiness method of claim 8, further comprising providing a peer supportsystem that empowers said client through customized self managementeducation and problem solving skills to improve a health, communityintegration, employment readiness, financial well being and overallquality of life of said client. 10) The business method of claim 1,further comprising promoting personal accountability through thedevelopment of an Individual Development Plan (IDP) and self managementeducation; and utilizing action learning and peer support teamprinciples to promote self determination, advocacy, gainful employment,and independence. 11) The business method of claim 10, wherein saidaction learning empowers clients to solve problems with peers and casemanagers, said problems associated with a clients' health managementservice and reimbursement policies. 12) The business method of claim 10,further comprising developing and implementing said coordinated healthcare delivery and services in phases consisting of primary and secondaryintervention strategies, wherein a Primary intervention is based on anindividual development plan, and a secondary intervention is based on aservice system including at least one of clinical, educational,community, vocational services and benefit counseling. 13) The businessmethod of claim 10, further comprising imposing evaluative mechanismsfor streamlining accountability of said coordinated health care servicesand delivery program for the individual participant and for thecoordinated health care system in an entirety, wherein said evaluativemechanisms include at least one from the group comprising: efficacy ofrecruitment, attainment of IDP goals, clinical goals outcome, jobreadiness and actual placements, assessment of participant satisfaction,and quality of life measures. 14) A coordinated service delivery programfor coordinated health and human services management comprising: anintake assessment and recruitment module for population stratificationand recruitment for clients having chronic disease or disability; aprimary intervention module for developing an individual developmentplan and for enacting action-learning through peer support teamintervention; a secondary intervention module for providing coordinationof services; and an information archive to coordinate services formonitoring and tracking client progress; wherein the coordinated servicedelivery system is a population-based, client-centric strategy thatcombines self-management skills with said services to facilitatefunctional and psychosocial needs of the client for focusing oncommunity integration and re-employment. 15) The coordinated servicedelivery program of claim 14, further comprising a program evaluationmodule for evaluating performance indicators against external indicatorsfrom a control group; and a policy recommendations module to reviewfindings in view of said performance indicators and to makerecommendations based on performance results from said coordinatedservice delivery program. 16) The coordinated service delivery programof claim 15, wherein the program evaluation module further providesindividualized outcomes studies for developing outcome health carestudies for evidence-based healthcare programs. 17) The coordinatedservice delivery program of claim 14, wherein the evaluation moduleanalyzes and measures an effectiveness of the coordinated servicedelivery program. 18). The coordinated service delivery program of claim14, wherein the program evaluation module standardizes said deliveryprogram on clinical, social, behavioral, and economic indicators tomeasure and analyze overall program and individual client performance.19) The coordinated service delivery program of claim 14, wherein theintake assessment and recruitment module further comprises collectinglong term clinical, behavior, and compliance information to evaluatelong term study outcomes; and developing a profile of clientqualification criteria for recruiting clients approved with the supportof all program stakeholders. 20) The coordinated service deliveryprogram of claim 14, wherein the intake assessment and recruitmentmodule further comprises: entering the analysis of pre-screened clientsinto a program database; interviewing the pre-screened clients fordirectly assessing their needs and interest in participation of saidservice delivery program; selecting qualified clients, enrolling clientsin an orientation program, and assigning clients to a peer support team;updating the program database for qualified and unqualified clients;measuring baselines such as clinical history, or quality of life survey;and creating an individual development plan (IDP) for a client togetherwith family members, peers, and other program stakeholders of the peersupport team. 21) The coordinated service delivery program of claim 14,wherein the intake assessment and recruitment module further comprisesanalyzing at least one of demographic, employment history, prevalence ofchronic disease, other health factors, utilization and other riskstratification factors for chronic disease and disability. 22) Thecoordinated service delivery program of claim 14, wherein the IDP of theprimary services intervention is a multifaceted document which providesthe clinical background and life history of the client including atleast one of education, training received, family information, andemployment history. 23) The coordinated service delivery program ofclaim 14, wherein the IDP further includes at least one of demographicinformation, health status information, community information, socialservices information, vocational information, and employmentinformation. 24) The coordinated service delivery program of claim 14,wherein the services include: a clinical services domain for monitoringchronic disease indicators captured during peer support team meetingsthat are archived in a database for complying with the IDP; an educationservices domain for providing preventative education for family membersof clients with chronic disease and disability; a community servicesdomain for supporting active daily living of clients for overcomingemployment and community integration barriers; and a vocational servicesdomain to facilitate a coordinated continuum of services for providinggainful employment opportunities. 25) The coordinated service deliveryprogram of claim 14, wherein said information archive provides real timeand secure access to program information. 26) The coordinated servicedelivery program of claim 24, wherein said clinical services domainincludes at least one of risk stratification, compliance monitoring,wellness/fitness programs, prescription drug and counseling programs,nutritional and supplemental programs, home healthcare encounters,outpatient primary care encounters, and inpatient encounters. 27) Thecoordinated service delivery program of claim 24, wherein said educationservices domain includes at least one of self-management education,advocacy training, continuing education training, micro-computertraining, and technical assistance. 28) The coordinated service deliveryprogram of claim 24, wherein said community services domain includes atleast one of housing services, transportation services, accessibilityservices, adaptive technology services, and recreation services. 29) Thecoordinated service delivery program of claim 24, wherein saidvocational services includes at least one of job readiness training,mentorship and internship programs, networking development, resume andinterviewing skill development, and job listings and postings. 30) Thecoordinated service delivery program of claim 14, wherein saidinformation archive is monitored on-line by one of a Support ServiceManager and a PST coach. 31) The coordinated service delivery program ofclaim 14, wherein the program evaluation module further comprisesassessing employment indicators including at least one of hours worked,job retention, informed choice, control, satisfaction, level and natureof required supports, and employer satisfaction. 32) The coordinatedservice delivery program of claim 14, wherein the delivery processesmodule guides the client through program phases to build theircapability to live a full life and find meaningful employment throughsaid Action Learning. 33) A method for coordinated health and humanservices delivery comprising: assessing and recruiting clients anddeveloping a team of professionals and third party providers; developingan individual development plan for said clients; supporting servicegroups and managing services for clients through action-learning andPeer Support Team Intervention; and sharing and archiving informationfor consolidating data from said services and for monitoring andtracking client progress. 34) The computer implemented method of claim33, further comprising delivering said services for providing access toa multi-disciplinary team of experts; and analyzing and measuring theeffectiveness of a coordinated service delivery program to providehealthcare, community integration, and employment services to a client.wherein the delivery is a population-based, client-centric strategy thatcombines self-management skills with coordinated services to facilitatefunctional and psychosocial needs of said client for focusing oncommunity integration and re-employment. 35) The method of claim 33,further comprising standardizing said delivery on clinical, social,behavioral, and economic indicators to measure and analyze overallprogram and individual client performance. 36) The method of claim 35,further comprising recommending policies and guidelines based on saidperformance. 37) The method of claim 33, wherein the assessing andrecruiting clients further comprises: collecting long term clinical,behavior, and compliance information to evaluate long term studyoutcomes, and developing a profile of client qualification criteria forrecruiting a client with the support of all Program stakeholders. 38)The method of claim 33, wherein the assessing and recruiting clientsfurther comprises: entering the analysis of pre-screened clients into aprogram database; interviewing one or more pre-screened clients inperson where they live for directly assessing their needs and interestin participation of the program; selecting one or more qualifiedclients, enrolling said qualified clients in an orientation program, andassigning said clients to a Peer Support Team; updating said programdatabase for qualified and unqualified clients; and measuring baselinesand creating an Individual Development Plan (IDP) in concert with familymembers, peers, and other Program stakeholder of the Peer Support Team.39) The method of claim 33, wherein the developing an IDP furthercomprises: capturing employment information from vocational assessments,resumes, internship, and mentorship opportunities, job postings, and jobretention data; and analyzing demographic, employment history,prevalence of chronic disease and other health factors, utilization andother risk stratification factors for chronic disease and disability.40) The method of claim 33, wherein supporting service groups andmanaging services further includes developing a team for working in anenvironment of Action Learning to maximize a capacity and ability tocollaborate with the client. 41) The method of claim 33, whereinsupporting service groups and managing services further includes:providing access to clinical, educational, vocational, and communityservices for placing the client in a supportive, nurturing and learningenvironment; providing said services and resource coordination ofservices through action-learning by linking said community services,vocational services, educational services, and clinical services topromote employment outcomes; and monitoring and tracking client progressto facilitate a coordinated continuum of services for ensuing gainfulemployment opportunities. 42) The method of claim 33, wherein supportingservice groups and managing services for clinical services furtherincludes providing at least one of risk stratification, compliancemonitoring, wellness/fitness programs, prescription drug and counselingprograms, nutritional and supplement programs, home healthcareencounters, outpatient primary care encounters, and inpatient encountersfor monitoring chronic disease indicators captured during peer supportteam meetings that are archived in compliance with an IDP. 43) Themethod of claim 33, wherein supporting service groups and managingservices for educational services further includes providing at leastone of self-management education, advocacy training, and continuingeducation and training for providing preventative education for familymembers of clients with chronic disease and disability. 44) The methodof claim 33, wherein supporting service groups and managing services forcommunity services further includes providing at least one of housingservices, transportation services, accessibility services, adaptivetechnology services, and recreation services for supporting active dailyliving of clients to overcome employment and community integrationbarriers. 45) The method of claim 33, wherein supporting service groupsand managing services for vocational services further includes providingat least one of Job Readiness Training, Mentorship/internship Programs,Networking Development, Resume and Interviewing Skill Development, andjob listings & postings. 46) The method of claim 33, wherein analyzingand measuring the effectiveness of a coordinated service deliveryprogram further includes: providing secure interactive communication andaccess to program information; consolidating data from variousinformation sources; presenting said data to clients in a seamlessmanner; and reporting outcomes of said health care delivery program. 47)The method of claim 33, wherein analyzing and measuring theeffectiveness of a coordinated service delivery program further includescollecting and archiving clinical encounters or clinical indicatorinformation captured from client diaries and PST clinical datacollection for analysis. 48) The method of claim 33, wherein supportingservice groups and managing services provides an administrative focususing a Support Service Coordination Group (SSCG) Task Team by:assigning at least one Support Service Group Coordinator; assigning atleast three Learning Coaches; assigning at least nine PSTs; andassigning at least one Hybrid Action Learning Team. 49) The method ofclaim 33, wherein supporting service groups and managing servicesprovides an administrative focus using at least one of a Peer SupportTeam (PST) Task Team, a Learning Coach, and a Peer Support Circle. 50)The method of claim 33, wherein supporting service groups and managingservices provides an administrative focus using a Peer Support CircleAction Learning Team. 51) The method of claim 33, wherein supportingservice groups and managing services provides an administrative focususing a Hybrid Action Learning Team by assigning at least One ActionLearning Team. 52) The method of claim 33, wherein supporting servicegroups and managing services provides an administrative focus using anAdvisory Council Task Team. 53) A method of providing coordinatedhealthcare to promote community integration and employment for personswith disabilities comprising: providing active recruitment of eligibleparticipants; providing a support service coordination system that isconsumer-driven using a peer supported Action Learning approach tocoordinate, advocate and manage services; and providing a comprehensiveand coordinated network of support services through an integratedservice network. 54) The method of claim 53 further comprising:providing a peer supported process of Action Learning of interactiveproblem solving to improve long term “Lifestyle” changes and promoteconsumer empowerment; and providing consumer incentives and benefits forclients to promote and sustain long term behavior changes; 55) Themethod of claim 53 further comprising: providing partnerships witheligible stakeholders including local and state provider agencies; andpromoting communication among critical stakeholders to capture andanalyze program data. 56) An information technology (IT) platform forproviding coordinated health care and human services managementcomprising: a healthcare management service; a self-management service;a community and vocational service; an outcomes research service; and anIT platform combining access to said services for coordinating andmanaging said services within said information technology (IT) platform,wherein the information technology (IT) platform is a population-based,client-centric entity that facilitates a focusing of a client'sfunctional and psychosocial needs on community integration andre-employment through the coordination and interaction of said services.57) The information technology (IT) platform of claim 1, furthercomprising public and private services, wherein the public servicesincludes at least one of general program marketing information, generale-mail, calendar, discussion groups and forums and general job placementinformation, and the private section of the platform is secure andprivate, and is divided into two main applications wherein the firstapplication contains clinical and self management data, and the secondapplication contains community and employment service information.